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IPAP > Surgery Block 4 > Flashcards

Surgery Block 4 Flashcards

1
Q

What are the 3 parts of the Trimodal Death distribution and injuries in each

A

Sec-Min:
Intracranial injuries
Transected vessels

Min-Hrs:
Sub/Epidural hematoma
Hemorrhage
Organ lacs
Pelvic Fx
Hemo/Pneumo Thx

Day-Wks:
Sepsis, MODS

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2
Q

How is medical control of the prehospital phase ensured?

What are the first two steps before the four steps of Field Triage?

A

Protocol trauma
Comms w/ Physician
Subsequent trips

VS, LoC

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3
Q

PTs who fall into ‘Immediate’ Triage means ?

What types of injuries would place PTs in this category?

A

Outcome depends on immediate interventions

Hemorrhage
Airway obstruction
Tension PTx
Retrobulbar hematoma
Amputation
Blunt/penetration w/ shock
Intracranial hemorrhage
Threatened limb loss
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4
Q

Four priority steps of ‘Immediate’ management

‘Delayed’ category of Triage means ?

What types of injuries does this category encompass?

A

Bleeding
Airway/ventilate
Circulation

Wounded but stable

FacialFx/injury w/ airway Non-life threatening burns
Globe injuries
Blunt/penetrate, no shock
Larger lacerations
Stable VS
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5
Q

What PTs may fall into the Minimal Triage category

Why are PTs in minimal category so dangerous?

What PTs may fall into the Expectant Triage category

A

Self care until Evac:
Minor lac/burn
Small bone Fxs

Overwhelm MassCas resources d/t bypassing MedEvac, self report

No VS on arrival
Shock
Head gunshot w/ coma
Severe burns
High spinal cord injury
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6
Q

Secondary survey’s start at ? and work ?

What are the two most rapid methods that PTs die from?

A

HEENT
Clavicles down

Loss of airway
Bleed: SBP <90+HR>130

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7
Q

Initial circulation check includes ?

By palpating BP on ? three locations can give BP estimates of ?

A

Pulse LoC Skin perfusion

Radial >80
Femoral >70
Carotid >60

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8
Q

What two parts of circulation exam give the PTs hemodynamic status?

Initial fluid resuscitation includes ? followed by ? empiric blood products

What are 3 types of injured PTs that would need this type of fluid resuscitation

A

LoC
Skin perfusion

1L isotonic crystalloid
1:1:1- PRBC Plasma Platelet

Complex pelvic Fx
US w/ Intraperitoneal blood
Bilateral femur Fx

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9
Q

Why does excess administration of crystalloids need to be avoided in trauma?

What type of blood bank order should be placed and ready w/in ?

What part of the disability assessment is the most predictive for the PT?

A

Exacerbates vicious triad: hypothermia acidosis coagulopathy

Type specific in 20min

Best motor score

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10
Q

PT w/ lateral gaze and dilated pupil means ?

Normal sizes should be within ? of each other and dilate more than ?

A

Stem herniation through tentorium cerebelli

1mm
>4mm

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11
Q

What are the parts of a 9 Line report

A

1: location
2: frequency
3: PT type
4: special equipment
5: PTs by type
6: security at scene
7: mark of LZ
8: nationality/status
9: NBC threat

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12
Q

The secondary survey may begin when and used ? acronym

What are the 3 priorities of the secondary survey

What is the MC error of the secondary survey

A

Primary survey complete
Resuscitation underway
Hemodynamic stable
AMPLE

ID all wounds
Need for urgent surgery/further tests

Failed ID of multi-injuries

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13
Q

Secondary survey decision making process is driven by what two factors?

Resuscitation efforts do not focus on normal VS but instead focus on ?

A

Hemodynamic stability
Location of wounds

Blood products
IV access
Transport to OR

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14
Q

? is the most valuable test of penetrating trauma

What are the indications to perform an urgent thoracotomy?

A

Determine trajectory w/ x-ray

> 1500 initial output
200/hr x 3hrs
Hemothorax w/ 2 tubes

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15
Q

? is the most reliable screening for intrathoracic and intra-abdominal bleeds?

What part of the body is more likely to conceal an occult bleed after blunt trauma?

A

Chest: CXR
Abdomen: fast

Abdomen

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16
Q

How much blood can the peritoneal cavity hold w/ possibly minimal distension?

Unstable pelvic trauma PTs w/ positive US need ? procedure

If there is no evidence of bleeding but PT remains unstable, what is the next Dx considered

A

3L

Laparaotomy

External pelvic fixation and pelvic packing
Angioembolization

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17
Q

? PT presentation after blunt trauma indicates need for emergency craniotomy

If hemodynamically stable obtain ? image

A

GCS <9
Lateralizing neuro exam

CT- dx tool of choice for suspected head injuries

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18
Q

Closed head trauma is rarely the cause of HOTN except ?

What is the gold standard initial screening tool for blunt trauma CVIs?

A

Final phase before herniation
Spinal cord injury association

CTA of neck

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19
Q

What blunt trauma chest injuries are ruled out during the secondary survey?

What injury needs to be r/o if PT has Fx of first rib

A

Pulmonary contusion
Blunt trauma to RV/Aorta
Rib Fx

Blunt cardiac injury
Apical tumor S/Sxs

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20
Q

Pt w/ flail chest and pulmonary contusions needs ? early intervention

What is the MC location of blunt aorta injuries to occur?

What may be seen on CXR indicating injury presence?

A

Intubation

Distal to L SCA take off

Mediastinum >8cm
Apical cap

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21
Q

Any PT w/ mechanisms suspicious for aortic injury needs ?

What happens to PTs w/ blunt trauma after FAST exam

? is the MC injured GU organ, what is the most reliable sign of this injury, and what is the first line image ordered

A

CT angiogram

+ FAST and unstable: OR
+ FAST and stable: CT w/ contrast

Renal injuries
Hematuria
CT

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22
Q

How are renal injury PTs managed post-op?

? organ damage is highly probable w/ pelvic Fx

Perform ? procedure prior to cannulation

A

Bed rest until clear urine
Foley cath until PT controls urge
F/u CT 48-72hrs

Bladder

Cystogram

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23
Q

What does an extended FAST include?

What does subcutaneous emphysema look like on CXR

A

Eval for Hemo/Pneumo thorax

Comb like, striated appearance

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24
Q

Where do subpulmonic effusion develop?

What would be fiver terms used to describe their appearance

A

Between visceral pleura and diaphragm

Blunting angles
Meniscus
Opacified hemithorax
Loculated

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25
Q

Define Fissural Pseudotumors

These are usually associated with ?

A

MC- Fluid trapped between minor fissure layers

CHF

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26
Q

Define Laminar Effusions

Define Hydropneumothorax

A

Density on lateral chest wall near angles

HemoPneumo- air and fluid

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27
Q

Three foramen in diaphragm allow for passage of ?

Diaphragm injuries are usually seen on ? side after inserting ?

How are these injuries Tx

A

Vena cava
Esophagus
Aorta

L side, NG tube

Transabdominal surgery

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28
Q

Ascending aorta usually doesn’t go farther R than ?

Aortic dissections MC originate ?

A

RA border

Stanford A, ascending aorta

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29
Q

What C-spine image may be used for starting?

What are normal spaces in the C-spine that alterations would indicate soft tissue edema

Loss of lordotic curve on lateral c-spine images indicates?

A

Lateral

C2- 6mm
C6- 22mm

Tissue swelling
Muscle spasms

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30
Q

Hangman Fx

When are these considered stable and how are they Tx

A

Traumatic spondylolisthesis:
Axial compression and hyperextension= bilateral pars Fxs

W/out C2-3 angulation
Philadelphia collar/SOMI brace x 12wks

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31
Q

Jefferson Fx

Since most of these don’t present as isolated Fx, what else is usually present?

A

Atlas Fx from axial loading, usually w/out neuro injury

C2/Axis Fx

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32
Q

Clay Shoveler’s Fx

How are these Tx

A

C7 spinous process fx w/ unilateral lamina/pedicle Fx

Rigid cervical collar

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33
Q

Hyperflexion injuries are usually ? injuries

How does these change once classified as Tear Drop Fx

A

Flexion and distraction

Severe hyperflexion w/ posterior displacement
PTs usually quadriplegic

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34
Q

Hyperextension injuries are usually ? types of injuries

Most of the time PTs will have ? neuro Sxs

Bilaminar Fxs can be accompanied w/ ?

A

Extension and compression- forehead blow Fx posterior complex

Radiculopathy

Complete cord lesion

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35
Q

Bilateral vertebral arch Fxs are yperextension injuries that have complete ? translation of vertebral body

These PTs can present w/ one of what 3 issues

What do they rarely have?

A

Anterior

Radiulopathy
Central cord syndrome
Incomplete cord lesion

Complete cord lesion

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36
Q

What part of C2 is MC Fx

What are the 3 types

A

Odontoid

Type 1: tip
Type 2: neck, ground level fall in elderly PTs
Type 3: junction of process and body

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37
Q

Why do most PTs not survive AOD injuries

When would this Dx be changed to AAD?

A

Brain stem injury, respiratory arrest

Prevertebral swelling on x-ray
CT of SAH at craniovertebral junction

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38
Q

Where do most Fxs of lumbar spine occur

What are the 3 parts of the Denis three column principle here

A

T12-L1 junction

Anterior
Posterior
Intertransverse ligament

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39
Q

What are the four major types of thoracolumbar spine injuries?

A

Compression Fx
Burst Fx
Chance fx
Fracture-dislocations

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40
Q

What is the criteria for an L-spine compression Fx

How are these Tx

What if the risk if the criteria is not met and exceeded?

A

<50% loss of height
<30% angulation
Intact posterior column

Analgesic
Bed rest

> 50% height loss- inc risk for kyphosis

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41
Q

Define L-spine Burst Fx

What are the indications these need surgical correction?

A

Unstable Fx even if no neuro Sxs, avoid early ambulation

> 50% loss of height
Canal narrowing >50%
Kyphotic angle >25*

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42
Q

L-spine transverse Fxs are normally ? and best assessed via ?

Define Young-Burgess Classifications for pelvic Fx

Define AO Tile Classifications

A

Stable
AP x-ray view

Force of vectors causing Fx

Degree of in/stability

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43
Q

What are the three categories of Young-Burgess Fxs

What are the 3 AO-tile classifications

A

Lateral
Anteroposterior
Vertical force

A: ring intact
B: rotation unstable, vertically stable
C: ant/posterior instability

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44
Q

Most PTs w/ femoral neck Fx present looking like ?

What is the sequence for evaluating abdominal x-rays

A

Short, external rotation and abducted

Gas pattern
Extraluminal air
Calcifications
Soft tissue masses

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45
Q

What x-ray findings indicate the spleen is enlarged?

Hemodynamically stable PT w/ positive FAST gets ? imaging and ? procedure

A

Protrudes below 12th rib
Pushed gastric bubble past midline

CT w/ contrast
Extravasation= hollow viscous injury, exploratory laparotomy

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46
Q

PTs w/ abdominal trauma causing solid organ injury w/ evidence of bleeding should have ? considered

This adjunct when done early is good for managing ? injuries

A

Angiography

Liver, Spleen, Kidney injuries

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47
Q

Extremity x-rays are always taken on what two planes?

When do these x-rays need to be repeated?

A

AP and Lat

After reduction

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48
Q

? is the image of choice for detecting intracranial bleeds

What are the 4 areas these bleeds can occur or accumulate

A

HT CT

Subarachnoid
Epi/Subdural
Prenchyma

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49
Q

What is the initial step when Tx TPs w/ blunt thoracic trauma?

What types of chest wall injuries have to be Tx w/ surgery

A

Airway management

Penetration w/ >1L blood loss
Diaphragm rupture
Aortic transection
Cardiac tamponade

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50
Q

? is the initial imaging ordered for chest wall injuries

? is the MC chest wall injury from blunt trauma

A

Portable CXR

Rib Fx

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51
Q

How are PTs w/ flail chest and unable to cough Tx

When do these PTs need to be intubated

A

Pulmonary toilet

Dec pulm function w/ worsening hypoxia/hypercarbia w/ adequate pain control

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52
Q

How are PTx Dx w/ CXR

When are these categorized as occult?

How are these occult ones Tx

A

Exhalation

PTx on CT but not seen on CXR

Observed

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53
Q

What are 3 possible complications to arise from hemothorax Tx

What image may be ordered to help show size and location?

A

Atelectasis
Empyema
Retained hemothorax

Thoracic CT

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54
Q

Pulmonary contusions causes the systemic activation of ?

What imaging is best for visualization and assessment?

These injuries are well known RFs for PTs to develop ?

A

Innate immunity- release of interleukins, prostaglandins and chemokines

Chest CT

Pneumonia
Sepsis

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55
Q

Chylothorax development is more likely to develop after ? but rarely after ?

If rarely develops, what causes it

A

Common- iatrogenic
Rare- trauma

Axial chest injury
Spine Fx

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56
Q

How are chylothoraxes Dx

These can often drain more than ? per day and be considered normal

How are chylothoraxes Tx

A

Chylomicrons and Inc Tg in pleural effusion w/ milky white appearance

1L/day

Dec/stop Tg intakes
Surgery if Tx failure

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57
Q

Most PTs don’t survive aortic transections unless ? structure holds?

? is the gold standard imaging for great vessel injury from penetrating trauma

How are these injuries usually exposed during Tx

A

Adventitia

CT angiography

Median sternotomy

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58
Q

What is the MC location for the heart to be injured from trauma?

What PE finding may occur w/ Beck’s Triad but is rarely detectable

A

RV

Pulsus paradoxus

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59
Q

What is the first imaging test conducted on PTs w/ high risk chest penetration wounds?

What is the next step for PTs w/ obvious cardiac tamponade and not in immediate arrest?

What is the next step if PT has risk factors?

A

FAST

OR for sternotomy

EKG
Abormal EKG= Echo

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60
Q

What are the immediate steps taken for PTs w/ cardiac arrest from pericardial tamponade?

When are resuscitative thoracotomys best for blunt or penetrating trauma?

PT must have ? to even consider this Tx

A

Thoracotomy w/ pericardiotomy

Penetrating: CPR <15min
Blunt: CPR <10min

Organized rhythm, even PEA

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61
Q

When performing resuscitative thoracotomy, what caution needs to be taken?

What types of airway disruptions can create the need for this procedure

A

Phrenic nerve on posterior side of heart

Pulmonary lac w/ hemorrhage
Hilar twist
Staple wedge resection

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62
Q

Why would delayed exploration of the chest need to be conducted

What are the two approaches to conducting delayed exploration of the chest?

If both sides of the chest need to be opened, what type of procedure can be converted for the need?

A

Hemorrhage, small/missed
Empyema post trauma
Retained hemothorax

Medial sternotomy
Posterolateral thoracotomy at 4-5th ICS

Post-Lat to Bilateral Clamshell

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63
Q

What are the two relative c/is for doing a chest thoracotomy?

What are the 3 maneuvers conducted to prevent bleeding complications?

A

Blood dyscrasia
Anticoagulation

Enter pleura above rib, avoid neurovascular bundle
360* finger sweep
Controlled pleural entry

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64
Q

What are the borders of the triangle of safety for a thoracotomy procedure?

Where is the insertion site marked on the PT

A

Medial: pec muscle
Lat: lat dorsi
Inferior: 4-5th ICS

5th rib AAL in triangle/

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65
Q

How many applications of sterile solution are applied prior to a thoracotomy

What are used for drapes/coverings?

A

3 in circular motion

Fenestrated
3-4 towel technique

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66
Q

What is the best location for a closed thoracostomy tube

What material is used to suture tube in place?

A

5/6th ICS anterior mid-axillary line

0 or 1 silk

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67
Q

How much water is placed in a pleur vac suction chamber?

How much water is placed in the air leak meter?

A

20cm

2cm

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68
Q

What pleur vac indication means there is an air leak?

How is post-placement CXR verified

How far into chest does tube go?

A

Leak meter bubbles and doesn’t settle after 1min

Last fenestration in chest w/ radiopaque break in line

Hugs wall up to apex

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69
Q

Initial setting for chest tube maintenance is on ?

What happens if this setting is inappropriately shifted to wall suction?

A

Water seal then low wall suction 1-2hrs after insertion

Pulm edema refractory to diuretics

70
Q

How much fluid is produced by the lung and pushed through the chest tube?

What are 3 chest tube maintenance checks done every day?

A

100-150ml/day

Air leak check
Drainage check
CXR

71
Q

What is the acronym for trouble shooting chest tubes?

What is done if an air leak is identified

A

DOPE- Displaced Obstructed Position Equipment failure

Check vac connection tube
Check insertion site
Both ok= lung injury etiology

72
Q

When are chest tube removals considered?

What does PT need to do during extraction?

A

No air leak in water seal
<200ml drained x 24hrs
No PTx

Hum

73
Q

? organs are in the anterior abdomen?

What organs are in the retroperitoneum

A

Liver Spleen Transverse colon Small intestine

Duodenum
Pancreas
Kidney
Aorta
Vena cava
74
Q

? hollow organ is MC injured in blunt trauma?

Dx laparoscopy is performed on ? PTs to establish ?

What are the 3 main indication to perform a laparotomy?

A

Duodenum- posterior located pressed against solid structure

Stable w/ penetrating trauma
Peritoneal penetration or not

Peritonitis
Intra abdominal hemorrhage
Presence of injuries

75
Q

? Dx is rare after blunt abdominal trauma

Absence or presence of bowel sounds during abdominal trauma HnP means ?

A

Peritonitis

Presence- doesn’t r/o intra-abdominal injury
Absence- does not prove intra-abdominal injury

76
Q

What type of abdominal trauma can cause ileus

During percussion the abdomen, dullness can indicate ? while hyper tympany can mean ?

A 
Hypovolemia
TPTx
Tamponade
Peritonitis
Lumbar spine injury

Intraperitoneal bleed
Intraperitoneal air

77
Q

What labs are ordered during abdominal trauma?

What are the limitations of CT in abdominal/pelvic trauma assessments?

A

CBC CMP UA
Amylase/Lipase if pancreas injury suspected

Miss hollow viscous injury
Fat stranding
Pneuoperitoneum
Free fluid

78
Q

? PE finding doubles relative risk for PT to have small bowel injury

Pts w/ ? types of Fx need to have hollow viscous injury suspected?

A

Seat belt sign

Chance Fxs

79
Q

What are 3 lab abnormalities that may point towards presence of hollow viscous injuries?

GSWs to abdomen get ? procedure

? is the exception to this rule

A

Inc WBC
Amylase
Lactic acid

Exploratory laparotomy

Tangential wound- laparoscopy, peritoneum violation turns into laparotomy

80
Q

? have a lower incidence for intra-abdominal injury than GSWs

PTs w/ eviscerations have ? procedure

A

Stab wounds

Laparotomy

81
Q

How are blunt trauma PTs need for surgery assessed?

A

No hemorrhage- Monitor, non-op Tx w/ serial exam/images

+ hemorrhage- monitor if stable, preferred for Peds

Unstable, usually d/t liver/spleen- OR

82
Q

3 true facts about blunt injuries to abdomen

What is a false fact?

? is the MC organ injured during blunt trauma

A

Cause duodenum hematoma
Causes more diaphragm injuries than penetrating
Can rupture hollow viscus

All need to be explored

Liver

83
Q

What are indications to repeat imaging for ASx liver trauma PTs

When do these injuries need to be re-imaged prior to return of sports?

A

Grade 4 or higher w/ US
Grade 4-5: repeat CT

4-8wks after injury
3mon prior to sports

84
Q

How are spleen injuries managed?

PT w/ abdominal trauma, air around kidney w/ RLQ crepitus means ? structure is injured

A

HOTN/Peritonitis- laparotomy
Stable- eval w/ CT
GSW- laparotomy
+ FAST + HOTN- laporotomy

Duodenum

85
Q

What may be see on x-ray after duodenal/pancreatic trauma

When/why would repeat images be needed

A

Intra/Retroperitoneal air
Obliterated psoas shadow

Initial negative CT but high suspicion remains

86
Q

What is the first step taken for suspected pelvis Fx

Why are these steps taken?

A

Splint/sheet wrap
Wrap legs together

Reduce intrapelvic volume
Leg wrap= internal rotation

87
Q

What is done to determine if pelvic Fx blood is venous or arterial?

What is the next step if artery is source?

What is the next step if venous source?

A

Contrast CT

Antiographic embolization

External fixation

88
Q

ACS causes ? to occur in the PT?

If abdomen is closed, what needs to be monitored?

A

Inc peak airway pressure and vascular resistance
Dec CO

Acidosis
Inc lactate
Dec urine output

89
Q

What are two types of drains may be used for abdominal/pelvic trauma during post-op care

A

Jackson Pratt- grenade shaped vacuum system under pressure

Penrose- prevents wound healing and allows seroud drainage; open and not under suction

90
Q

Define Consciousness

What are the two parts

A

Subjective experience of environment and self

Arousal- wakefullness
Awareness- phenomenal perception

91
Q

? defines the level of consciousness

Define awareness

A

Arousal response

Defines content of consciousness

92
Q

Define Alert

Define Stupor

Define Obtunded

Define Vegetative

Define Comatose

A

Awake, responds to stimuli

Less alert, responds to stimulation

Appears asleep, responds to noxious stimuli

Arousal w/out awareness

No response to stimuli

93
Q

Why does excessive cauterizing scalp bleeds need to be avoided

Scalp lacs are repaired in at most ? layers

Never use ? if a scalp Fx is present

A

Hair follicles in galea, can lead to alopecia

2

Active drain

94
Q

What are the layers of the scalp from out to in

What is a secondary brain injury that needs to be prevented

A

Skin CT Aponeurosa Loose tissue Pericranium

Hyperglycemia

95
Q

How often is a PTs need for artificial airway re-evaluated?

When do they need to be intubated?

A

5min

GCS 8 or lower
Motor of 4 or lower
Lost protective reflexes
Ventilatory insufficiency:
PaO2 <60
PaCO2 >45
Spot Hyperventilate PaCO2 <26
Respiratory arrhythmia
96
Q

What are the two worse secondary insults following a TBI

Severe O2 desaturation is categorized below ? and inc mortality x3

A

Hypoxia
HOTN

<60%

97
Q

What are sings PT is suffering from hypoxia

What PE tool can be used to indicate an adequate MAP pressure

A

Confuse Delerium Agitation
Coma
Peripheral constriction
Tachy/Tachy

Radial pulses

98
Q

Dec in MAP causes a dec in ?

MAP equation

How does this correlate if BP is 90/60

A

CPP

MAP= 1/3 (SBP + 2DBP)

1/3(90+120)= 70

99
Q

Equation for CPP

How is CPP measured

A

MAP - ICP

Centriculostomy placed by neurosurg

100
Q

Define Intracranial HTN

Where are ICP monitor bolts placed?

When are these placements indicated?

A

Inc pressure in cranium

Epi/Subdural
Intra-parenchymal
Intraventricular

GCS 8 or greater and abnormal head CT

101
Q

GCS scores

A

14-15: normal/mild
9-13: moderate
3-8: severe

E- 4
V- 5
M- 6

102
Q

Define Hyphema

Discovery on this during trauma exam can indicate ?

A

Blood pooling in anterior chamber

TBI sign

103
Q

What are two things that could cause pupils to be constricted?

What labs are ordered for decreased LoC

A

Narcotics
Organophosphates

CBC
Coag
E+s
ABG
Tox screen
Blood/CSF cultures
Thyroid function/B2/Cortisol- suspected endocrinopathy
104
Q

Acute ischemic strokes w/in first ?hrs can be occult on CT images

When would an MRI be warranted

A

3-4hrs

Characterize neoplastic lesion
Assess ischemic strokes

105
Q

Why would an EEG be ordered for Dec LoC?

Only order these after ?

A

Confirm global cerebral dysfunction
Exclude status epilepticus

Structural lesions have been excluded

106
Q

What does cerebral edema look like on CT images?

What does a midline shift mean and what wold be seen on PE?

What are the next steps done for these PTs?

A

Loss of grey/white differentiation

Herniated brainstem
Ipsilateral dilation, contra motor issues

Prevent HOTN, Hypoxia
Tx elevated ICP

107
Q

Subdural hematomas are due to ? and present in ? PTs

Epidural hematomas are due to ? injury and have ?

A

Ruptured vein in elderly PT

Middle meningeal artery trauma w/ lucid interval

108
Q

Define DAI

How do PTs present

A

Diffuse axon injury from shearing from accel/decell injury

Normal CT, shift or hematomas

109
Q

What is our BP goal during ICP

Why is this the target goal

What drug can be pushed to help manage shock?

A

SBP >90

Keeps MAP >70 and ICP <20

Phenylephrine

110
Q

What fluid is used for resuscitation during elevated ICP

Why would hypertonic saline be used?

How is this type of fluid not given?

A

NS until SBP >90 or palpable radial pulse

Max expansion, minimal volume

Not through peripheral IV

111
Q

How much mannitol is used during elevated ICP

What serial measurements need to be done on these PTs

A

0.25-0.5g/kg x 10-15min

Serum Na/osmolality
Renal funciton

112
Q

What drug combo is pushed for PTs w/ elevated ICP induced agitation

What med is used for an anti-seizure prophylaxis

What meds are reserved for refractory cases?

What is the last resort

A

Propofol + Fentanyl

Levetiracetam x 7 days

Barbituates

Decompressive craniectomy

113
Q

What is the MC complication for PTs after TBIs?

What E+ do TBI PTs tend to be low on and why?

A

Seizures

Na-
Cerebral salt wasting
SIADH

114
Q

What does Cerebral Salt Wasting occur after TBIs

What is the safest and most prudent Tx strategy for PTs w/ severe TBIs

A

Release of BNP

Euvolemia

115
Q

What are the 4 types of neurosurgical interventions for elevated ICP removal

What is the ICP goal for these procedures

A

Ventriculostomy
CSF drain
Decrompressive craniectomy
Barbituate metabolic coma

<20mmHg

116
Q

How do PTs w/ elevated ICP and brainstem herniations present

PTs w/ Tonsillar herniation classically present w/ ? Triad

A

Dilated, unresponsive pupil w/ lateral gaze- CN3 pressure from uncal herniation

Cushings Triad:
Inc SBP/wide pulse pressure
Bradycardia
Irregular respiratory pattern

117
Q

PTs w/ low GCS and ? PE finding is concerning for increased ICP?

If hyperventilation efforts are used to dec ICP, what are the capnography pCO2 goal ranges?

Why are these ranges needed?

A

Bradycardia

Normal resp: 35-45
Hyper vent: 26-30

Too much hyperventilation dec CPP to brain ischemia

118
Q

What are the 3 sequential stages of wound healing

What steps occur in each

A

Inflammation
Migration/proliferation
Maturation

Inflammation- constriction, coagulation to stasis
Prolongation causes abnormal healing

M/P- epithelialization in 24-48hrs, wound contraction

Mature: final phase, remodeling

119
Q

How long does it take for wound healing to reach 80% of original tensile strength

What are the 3 types of wound closure

A

6-8wks

Primary: suture/staple <8hrs from injury

Secondary: self heals, pack to allow healing from in to out

Tertiary: delayed primary, allows debridement

120
Q

What are the 5 steps to acute wound management

Define Contusion

A 
Stop bleeds
Debridement
Clean w/ saline
Examine depth/width
Close
Initial
Bedside exam
Anesthesia
Examine wound
Determine closure

Superficial wound w/ intact skin

121
Q

Define Abrasion

If left to heal by secondary intention, how long does this take?

What is done if wound is weeping proteinaceous fluids

A

Superficial damage to epi/dermis from friction

7-14days

Remove pseudoeschar

122
Q

What is the result if abrasions are not debrided in <48hrs of injury

Why are these types of injuries so painful

A

Traumatic tattooing

Exposed cutaneous nerves

123
Q

Term ‘laceration’ indicated ? tissue is damaged?

How long can these left open before they need to be closed

How are these prepared for healing if contaminated and why

A

6-8hrs
Face- <24hrs

Secondary intent- hematoma, necrosis or foreign body creates barrier to tissues

124
Q

How are crush injuries examined w/ images

These PTs need to be monitored for ?

A

US or MRI to eval for hematomas

Compartment syndrome- 6 Ps

125
Q

Suspected compartment syndromes need ? measurement taken

What result is positive

If Sxs persist, fasciotomies need to be performed w/in ?

A

Intracompartment mental pressure

> 30= + compartment syndrome

<6hrs

126
Q

Compartment syndrome can lead to ? two issues

What is initiated in these PTs as prophylaxis against HyperK

A

Rhabdo
Renal failure

Forced mannitol-alkaline diuresis

127
Q

What can cause extravasation injuries

Presence of ? RFs can indicate a more serious effect

A

Fluids in interstitial space
Occluded vessel
Dislodged catheter

High fluid volume
High osmolar contrast agent
Chemo agents
Cause ulceration/necrosis

128
Q

Extravasation Txs depend on ?

How are these Tx

A

Substance involved
Time of detection
Degree of damage

InD/ Aspiration
Graft/Flap coverage

129
Q

Bites over joints need to heal by ?

What prophylaxis is added for animal bites?

What ABX is added for human bites

A

Secondary intention/delayed primary closure

Rabies

Augmentin

130
Q

What snaked belong to elapids?

What type of toxin do they have that cause ?

A

Cobra
Mambas

Neurotoxic- cardio/pulm manifestations

131
Q

What snakes belong to Vipers

What type of venom do they have and that cause ?

A

Rattlers, Vipers

Cytotoxic- necrosis, hemolysis, compartment syndrome

132
Q

What two factors provide the best chance at optimal function after amputations

What are the 3 steps of primary closure

A

Bone length
Joint function

Pain control
Debride
Irrigate

133
Q

When are wounds allowed to heal through secondary intention?

How does wound closure happen by secondary closure?

A

Concern for contamination/infection

Granulation
Contraction
Epithelialization

134
Q

How are narrow punctures allowed to heal

How do wound vacs promote healing

A

Secondary intent w/ packing and daily changes

Stimulates fibroblast repair activity

135
Q

What Tx step may be attempted on surgical site infections?

Chronic wounds are usually seen in ? PT populations and due to ?

A

Wound vacs

DM, Obese
Malnutrition ImmSupp Infection

136
Q

What is the main factor leading to delayed wound healing?

How are decubis ulcers allowed to heal

A

Profound inflammatory state

Primary closure

137
Q

Foam dressings are best for ?

Alginate dressings are best for ?

Debridement dressings are best for ?

A

Absorbancy

Comfort

Debridement

138
Q

What are the 5 types of dressings for chronic wounds and what are the advantages/disadvantages of each

A

Simple: debridement, pain

Film: water resistant/not for grossly infected

Alginate: exudate, confused w/ slough

Foam: minimal pain, no monitoring

Hydrocolloid: little pain, not for grossly infected

Hydrogel: clears necrotic tissue, must use w/ secondary dressing

139
Q

What type of dressing can be used that has no absorption capacity w/ little hydrating ability?

After controlling infection, debridement and pressure of chronic wounds, signs of healing should show in ?

What is done if this time limit is not met

A

Transparent film

2wks

Quantitative bacterial wound culture w/ topical antimicrobials

140
Q

Define BMZ

What does this connect

Why is this layer important in burn healing?

A

Region of extracellular matrix

Basal cells of epidermis to papillary dermis via rete ridges

Protect from shearing forces during healing process

141
Q

What are the 3 zones of injury from burns

A

Central: most severe, coagulation, must be debrided

Stasis: constriction, ischemia, viable, may convert to coagulation

Hyperemia: dialation, viable

142
Q

Why do full thickness/3rd degree burns need surgical closure?

What type of burn is not applicable to Rule of 9s

A

No hair follicles prevents repopulation of new karetinocytes

First degree

143
Q

How are First Degree burns Tx

How do Second Degree appear?

A 
Acetaminophen/NSAIDs
Hydrating lotion (not alcohol)

Extend into papillary dermis w/ hallmark of blistering

144
Q

What are the two categories of Second Degree burns?

A

Superficial partial thickness- pink, moist, painful, heals w/out scar

Deep partial thickness- extends into reticular layer, pink/white, dry and variable pain
Heal w/ scar/contraction

145
Q

If partial thickness burn is not healed w/in ?wks ? is needed

What do Third Degree burns look like?

A

3wks, surgical excision and grafting

Through dermis in SQ
White/black and painless
Distinguished from superficial- NOT moist, no blanching

146
Q

How are Third Degree burns Tx

What is the critical time piece to this Tx

A

Excision and grafting, only heal by contraction of keratinocytes

Removal of eschar

147
Q

Superficial partial/second degree burns can be Tx w/ occlusive dressings to minimize exposure except for ?

What types of burns need topical ABX applied to them?

A

Face- Tx open w/ antibacterial ointment

Deep second degree
Third degree

148
Q

? Tx has no role in the management of acute burn wounds?

Why is this

A

Systemic ABX prophylaxis

Eschar has no microcirculation

149
Q

? med is the MC used for partial/full thickness burns?

What s/e may be seen?

A

SIlver sulfadiazine

Transient leukopenia

150
Q

What type of pain meds are preferred during debridement?

What imms needs to be given?

PT presents w/ 3rd degree burn after 8 days and is systematic, what is the best Tx step

A

IV

Tetanus

Remove burned skin, apply sodium mafenide

151
Q

How often are burn dressings changed?

What position are they splinted in

A

24-48hrs

Position of function

152
Q

What are the 3 types of skin grafts that can be done for burns?

What is the benefit of a full thickness graft

What are 3 locations this is used on?

A

Auto- from PT
Allo- same species
Xeno- other species

Full thickness of dermis, better cosmetic/function

Face Neck Hands

153
Q

When/where is a split thickness graft used for?

What benefit does this type of graft allow?

A

Meshed graft of healthy skin from donor site

Egress of serum/blood from wounds

154
Q

Greatest loss of fluid and protein from burns occurs in first ? hrs but capillary integrity can return w/in ? hrs

What causes the edema to develop?

A

6-8hrs
36-48hrs

Hypoproteinemia

155
Q

? type of burn Pt may have an increased instability of hemodynamics?

What fluid issues are unique to burn PTs

What happens as plasma volume is depleted?

A

Smoke inhalation

Edema
Fluid shifts
Inc capillary permeability

Inc extracellular fluid
Intravascular hypovolemia

156
Q

What are the two formulas used for fluid replacement in burn victims

What is the equation

What is the first fluid used?

A

Baxter/Parkland formula

4ml x TBSA x Kg
1/2 fluid in first 8hrs, rest over 16hrs

Initially- LR

157
Q

While delivering fluids via Baxter equation, PTs are at risk for developing ? and may require ?

What is the targeted range for UOP in these PTs?

A

AKI, vasopressors

0.5ml/kg/hr

158
Q

What procedure is performed to relive circumferential burns?

Burns cause bodies to enter hypermetabolism and increase the secretions of ?

A

Escharotomy

Catecholamines
Cortisol
Glucagon
Renin-angiotensin
ADH
Aldosterone
159
Q

What effects increase the body’s obligatory hypermetabolism reflex after burn injuries

How long does the hypermetabolic reaction last

What meds can be used to decrease this response

A

Pain
Cooling
Sepsis syndrome

7d

BB- dec catabolism
Insulin GH Testosterone analogue- dec catabolism, increase anabolism

160
Q

Burns that heal in position of comfort and not function are corrected w/ ?

What are the 3 types of electrical burns?

A

Z-plasty

Current
Thermal from arcing
Flame

161
Q

How are electrical burn PTs Tx

How are cord biting injuries Tx

A

Admit- burn unit
Cardiac monitor d/t cell damage leaking K+
Fluids/Serial long bone eval

Splint to avoid contracture
Reconstruct after healing

162
Q

Acid burns cause ?

Alkaline burns cause ?

? is one of the MC causes of hospital associated infections

A

Coagulation necrosis

Liquefaction necrosis

Post-op infections

163
Q

What are the 3 factors that determine the infectious process

? are a more important cause of SSI than exogenous bacteria

A

Organism
Environment
Host defense mechanisms

Endogenous

164
Q

What are the most frequently pathogenic bacteria in surgical PTs

? is the MC encountered enterococcal species

What is the MC species encountered that is Vancomycin resistant

A

Gram + Cocci: Staph A Strepto Enterococcus
Gram - Bacilli: Pseudomonas E Coli

E faecalis

E faecium

165
Q

Pre-op hand wash includes washing all four surfaces of each finger ? times

If become contaminated in OR, who removes/reapplies gear

A

20

Circ: removes glove
Scrub: regloves

Sleeve: scrub

Circ: removes gown
Scrub: re-gown

166
Q

Define Avagard

When can this be done

How is this done?

A

Pre-surg scrub done in lieu of full scub ir:

Full surgical scrub done for first case
No departure of the OR
No bathroom/eat/smoke break

One pump on hand
One pump on arm, wrist to elbow

167
Q

PTs w/ US confirmed hemopericardium and tamponade go to OR for ? procedure

What is a temporary measure done for these PTs that is not a definitive Tx

A

Sternotomy

Pericardiocentesis

168
Q

PTs w/ persistent signs of pericardial tamponade, tachy and JVD, but a normal sonogram go to OR for ?

What temporary procedure is done if PT doesn’t make it to OR

A

Subxyphoid window

Resuscitative thoracotomy

169
Q

What CT results indicate possible hollow viscus injury in abdomen?

What is the next step after these findings?

A

Free fluid
Mesenteric/boewl wall thickening

Serial PEs
Amylase level checks

170
Q

Topical ABX

Sequence of primary closure

Contracture AKA ?

A

Deep partial/3rd burn
Chronic wound
Face

pain clean irrigate

Stricture

171
Q

What burn PTs need pain meds

A

1st 2nd Circumferential

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